2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY - Undergraduate Nursing and Midwifery 4th Year Students Plans for When they Graduate - INMO

2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY - Undergraduate Nursing and Midwifery 4th Year Students Plans for When they Graduate - INMO
Undergraduate Nursing and Midwifery 4th Year
       Students Plans for When they Graduate

                                 May 2018 INMO
2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY - Undergraduate Nursing and Midwifery 4th Year Students Plans for When they Graduate - INMO
Page |1

Section 1.
       Executive Summary                                             2
Section 2
       2.1Background                                                 3
       2.2 Rationale                                                 5
       2.3 Methodology                                               5
Section 3.
       INMO Nursing and Midwifery Internship Survey 2018
       Individual Question Summaries                                 6
       Summary of Findings                                           11
Section 4.
Recommendations                                                      11
Section 5.
       Comments                                                      14
       5.1 Increases in pay                                          14
       5.2 Staffing Levels and Working Conditions                    15
       5.3 Emigrating                                                16
       5.4 Further Education and Career Prospects                    17
       5.5 Supported learning Environment.                           18
       Acknowledgements                                              19
       Reference List                                                20

2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY - Undergraduate Nursing and Midwifery 4th Year Students Plans for When they Graduate - INMO
Page |2

Section 1
Executive Summary
The purpose of the survey was to gather statistics and identify trends amongst
the 2018 nursing and midwifery internship students with a focus on their future
plans for working in the Irish Public Health Sector. These interns are due to
qualify in 2018.
71% are considering leaving Ireland.
60% are considering leaving the public health services to work in the private
57% have already been approached by overseas nursing companies.
 18% have been offered permanent contracts by the Health Service Executive
76% say staffing levels are not adequate to support learning and training of
student nurses and midwives in the clinical setting.
79% identify increases in pay and improvements in staffing and working
conditions as the required incentives to retain nurses and midwives in the
public services.

 The HSE must not neglect their responsibility in recruiting and supporting
                                            The Solution
 new graduates. The Irish public health sector must compete to retain
    1. Pay competitive rates for nurses and midwives of all grades to retain them within the public services.
 nursing   and midwifery staff; therefore, these incentives are required. This
    2. Recruit all graduates that have passed the final exams and assignments and have appropriate levels
 must be   an essential
       of competency         component
                       as outlined            for any strategy that wishes to address the
                                   by NMBI standards.
    3. Offerhospital
             permanentovercrowding            crisis, toexpand
                           contracts as an incentive                services
                                                          remain within          and health
                                                                           the public  support       any
                                                                                              services  with
       opportunities for a career break after 1 year.
 future development
    4. Provide               of the health
               a structured professional        service.
                                         development    plan for each new graduate including opportunities
         for funded post-graduate education and accommodating the individual’s preferences in
    5.   Ensure adequate support and supervision from mentors in the workplace.

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                               MAY 2018 INMO
Page |3

Section 2                                                      midwifery interns in relation to their plans post
                                                               qualification. These statistics provided
2.1 Background                                                 information, highlighting the main issues
The recruitment and retention of nursing and                   pertaining to the recruitment and retention of
midwifery new graduates in Ireland is a serious                nurses and midwives in the Irish public health
concern. In December 2007 the nursing and                      services:
midwifery WTE was 39,006. In December 2017                         •   78.1%     of     respondents  were
this figure was 36,777. That is a deficit of -2,229                    considering emigrating from Ireland
nursing and midwifery WTE in the irish public                          upon qualifying.
health sector.
                                                                   •   70.2% of the respondents had been
*On average there are approximately 800 Student WTE included
in these yearly figures.                                               approached by overseas recruitment
Annual Nursing and Midwifery Whole Time
Equivalent (WTE) Census 2007-2017                                  •   Of the 29.8% offered employment,
                                                                       only 16.25% had been offered
 December of Year         Total WTE         Change
                                                                       permanent contracts in Ireland at the
 2007                     39,006            N/A
                                                                       time of the survey. 58.92% of the
 2008                     38,108            -898
 2009                     37,466            -1,540
                                                                       respondents are considering moving
 2010                     36,503            -2,503                     to the private sector in Ireland but
 2011                     35,902            -3,104                     would stay if incentives were available.
 2012                     34,637            -4,369
                                                                   •   78.78% of the respondents stated that
 2013                     33,768            -5,238
 2014                     34,504            -4,502
                                                                       they would consider staying in the
 2015                     35,353            -3,653                     public service for at least a year upon
 2016                     35,835            -3,171                     qualifying if offered guaranteed
 2017                     36,777            -2,229                     permanent contracts.
Health Service Executive 2007-2017
                                                               This evidence highlighted the failings of the
The February 2017 agreed Nursing and                           Health Service Executive (HSE) in their
Midwifery Workforce Plan provides for a total                  fundamental obligation to proactively recruit
increase of 1,224 qualified WTE, however, by                   all new graduates. It also substantiates the
December 2017 a net increase of 847 WTE was                    claim that offers of incentives are essential to
achieved (additional vacancies due to                          entice these graduates to stay within the public
maternity leave continue to exist). It is                      health service in Ireland.
acknowledged that there was an effort by the
                                                               The INMO Nursing and Midwifery Internship
HSE to fill these posts but the retention
                                                               Survey 2017 showed that the top three ranking
problem negated the recruitment drive.
                                                               incentives to entice the graduates to stay
The Government’s ‘Bring Them Home’                             within the public health service are:
campaign, launched in July 2015, targeted 500
nurses and midwives employed in the UK.                            •   Increase in pay
Modest incentivised payments were offered to                       •   Improved Staffing Levels and Working
nurses and midwives working abroad to come                             Conditions
to Ireland. Only 91 nurses were enticed to
return to work in the Irish public health                          •   Access to      Funded     Postgraduate
service, 40 of these left prior to fulfilling a                        Education
year’s service.

In 2017 the INMO completed a survey to
examine the attitudes of nursing and

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                                   MAY 2018 INMO
Page |4

Pay                                                        The previous table shows that nurses in Ireland
                                                           are paid an annual salary substantially less
The International Council of Nursing (ICN) has
                                                           than nurses in the USA, Canada, Australia and
collected data on the purchasing Power Parity
                                                           the UK.
of nurses working in the public-sector hospitals
in 8 countries including Ireland. These figures            Nursing and Midwifery salaries v Health Care
show that Irish nurses and midwives are better             Assistant (HCA) salaries.
off financially if they move overseas.
                                                           Registered nurses/midwives are responsible
 Canada                          54,536                    for patient care and have a statutory obligation
 USA                             46,834                    to maintain the safety and welfare of patients
 Australia                       42,446                    through evidence-based practice. They may
 Japan                           40,951                    delegate appropriate aspects of that care to a
 Denmark                         37,537                    Health Care Assistant. However, in many
 Sweden                          34,025                    instances the registered nurse/midwife is paid
 New Zealand                     33,502                    less than the HCA to whom care is delegated.
 Ireland                         32,718                    The registered nurse/midwife remains
Source: International Council of Nurses (ICN)
                                                           accountable to the NMBI in respect of care
                                                           standards. The table below illustrates that a
Nursing and Midwifery employment in Ireland                staff nurse/midwife must reach point 5 of the
is largely within the public sector. The major             salary scale before she/he exceeds the
retention issue in this sector for nursing and             maximum point of the Health Care Assistant
midwifery grades is that the private domestic              salary scale.
and international competitors are offering
enhanced terms and conditions and better                   Differential between Staff Nurse/Midwife and
pay. As evidenced below, Ireland pays nurses               Health Care Assistant (HCA) Salary Scales.
and midwives at a lower rate than other                     Point of     Staff Nurse/Midwife €       HCA
graduate professions requiring the same entry               Scale                                    €
qualifications in the health service.                       Intern       14,150
Internationally, nurses are on a par or exceed              Pre-Reg.     24,604
the pay rate for Allied Health Professionals.               1            28,768                      27,102
Staff Nurse Salary Minimum Point of Scale in                2            30,802                      28,728
                                                            3            31,852                      30,001
Main Destination Countries for Irish Nurses (All
                                                            4            33,037                      30,678
Figures Presented as Purchasing Power Parity1
                                                            5            34,531                      31,418
Ratio 2017 Rates):                                          6            36,023                      32,178
                                                            7            37,508                      32,642
                                                            8            38,792                      33,433
                                                            9            40,080                      34,245
                                                           Source: Department of Health Consolidated Salary Scales

                                                           Hours of Work

                                                           Nurses/ midwives in Ireland work 39 hours per
                                                           week. This is 1.5 hours more than nurses in
                                                           Canada and the UK and 1 hour longer than
Sources: UK: NHS; Australia: Industrial Relations          nurses in Australia. It is 2 hours longer than
Commission of New South Wales; Canada: Health Science      Allied Health professionals who work a 37hour
Association of British Columbia; USA: US Bureau of Labor   week in Ireland.

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                                   MAY 2018 INMO
Page |5

Burnout                                            However available places were still
                                                   oversubscribed. It is imperative that greater
The RN4CAST Study (Scott et al. 2013)
                                                   efforts are made to retain new graduates in
identified burnout as a serious issue within the
                                                   Ireland. The INMO 2017 Nursing and Midwifery
Irish health system. The majority of nurses
                                                   Internship Survey highlighted the need for
working in medical and surgical units across
                                                   incentives for new graduates to remain in the
the acute hospital sector reported moderate to
                                                   Irish public health sector.
high levels of burnout and low levels of job
satisfaction.                                      The INMO 2018 Nursing and Midwifery
                                                   Internship Survey was designed to examine the
 The RN4CAST Study was a cross sectional
                                                   attitudes and plans of this year’s graduates
observational study in 10 European countries
                                                   regarding working in the public health sector.
and found that Ireland ranked among the
highest in relation to burnout. Nurses             2.3 Methodology
described burnout as the primary reason for
their intention to leave the profession.           The 2018 Nursing and Midwifery Internship
                                                   Survey questionnaire was adapted from the
Health and Safety                                  survey carried out by the INMO in 2017. One
                                                   change was made to the survey design. A
Nursing and midwifery are now high-risk
                                                   question was introduced to assess nursing and
occupations in terms of aggression and
                                                   midwifery intern’s attitudes towards the
physical assault. Between 1st January 2011 and
                                                   staffing levels in the working environments
27th July 2016, the numbers of physical
                                                   and how they affect the students learning.
assaults on staff in statutory acute hospitals
increased from 673 to 3,462. Of these 65%          The survey was designed using online software
(2,261) of the injured parties are recorded as     (Surveymonkey) and distributed through a link
nursing and midwifery staff, not including         sent to 800 students in total via e-mail and text
psychiatric nurses. (Casey, 2016) This equates     message.
to an average figure of 34 physical assaults on
nurses and midwives a month. Nursing and           The survey was opened on 21.02.18 and closed
midwifery make up 33% of the total public          on 07.03.18.
health service workforce, they are in the          The population size was 800 with a sample size
frontline, and carry the burden of trying to       of 417. The response rate was 52.13%
maintain a safe level of care within the reality
of increasing demands on services and
decreasing staff.       Unfortunately, these
statistics show that they personally now suffer
the consequences.

Acute hospitals are working above the
recommended 85% safe capacity rate which is
leading to stress and burnout. The highest
occupancy rate is evident in model 4 hospitals
with an average of 104%. (Department of
Health, 2018 Framework for Safe Staffing and
skill Mix))

2.2 Rationale
In 2017 the Central Applications Office AO
recorded a fall in applications for
undergraduate nursing of 5.47% (CAO 2017).

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                       MAY 2018 INMO
Page |6

Section 3                                           Question 3: Are you thinking about
                                                    emigrating when you qualify as a nurse or
Individual Question Summaries
Question 1: Are you male or female?
                                                                  Question 3
                   Question 1                        80


                           94.24                     60

                  Female           Male
 Answer Choices                 Responses      %
 Female                         94.24                30
 Male                           5.76                                             29.02

This question also has a purpose of                  10
allowing a comparison and contrast in
responses from male and female                        0
                                                                      Yes       No
Question 2: Are you under the age of 23?

                   Question 2
                                                     Answer         Responses                 %
                   Age Profile                       Yes            296                      70.98
                                                     No             121                      29.02
                                                    Question 3 examined the if student interns are
                                                    considering emigrating upon qualifying as a
                                                    nurse or midwife. As shown above 70.98% of
              23 years of age or younger            the respondents are considering emigrating
              Older than 23 years of age
                                                    when they qualify.

 Answer Choices                 Responses %
 I am 23 years of age or               67.15
 I am older than 23 years of           32.85
Question 2 examined the age profile of the
respondents. An individual that pursues 3rd
level education after the age of 23 in Ireland is
classed as a mature student. The age profile
will be used to assess responses for the age
demographics throughout the questionnaire.
 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                        MAY 2018 INMO
Page |7

Question 4: What incentives/changes                     48.92% of the respondents rank increases in
would prompt you to stay in the public                  pay as the most important incentive to keep
health service? (Chose in order of priority             them working in the public health service.
to you 1-6, 1 being the most & 6 less                   The next most important incentive was
important to you)                                       improved staffing levels and working
                                                        conditions (30.46%)
              Question 4
         Incentives Rating (%)                          Question 5: If an incentive(s) was given by the
 60                                                     employer, would you stay in Ireland as a

                                                                           Question 5

 30                                                                        33.45            37.16

 20                                                                                28.04


                        Category 1
                                                             Very likely
      Increase in pay
                                                             Somewhat likely
      Reduction in number of hours worked within a
      week i.e. the 37.5 hour working week restored          No as I wish to travel but will consider returning to
      Improved staffing levels and working conditions        work in Ireland if conditions improved.
      Rent allowances for staff working in major
      urban areas in ireland
                                                         Answer Choices                       Responses
      Access to funded post-graduate education           Very Likely                          37.16%
                                                         Somewhat Likely                      28.04%
 Incentive                              %                No, as I wish to travel but will     34.45%
 Increase in pay                        48.92            consider returning to work in
                                                         Ireland if conditions improve
 Reduction in number of hours           4.56
 worked within a week i.e 37.5                           Unlikely                             1.35%
 hour working week.
 Improved staffing levels and           30.46
                                                        Of the respondents that are considering
 working conditions.
 Rent allowances for staff              2.88            emigrating 65.2% would consider staying in
 working in major urban areas in                        Ireland if incentives were given. 34.45% wish to
 Ireland                                                travel but would consider returning to Ireland
 Access to funded Post-Graduate         6.71            if conditions Improved.
 Other                                  6.47

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                                 MAY 2018 INMO
Page |8

Question 6: Would you delay your                       The survey commenced on February 21st 2018,
departure for a year if your employers                 and was closed on March 7th 2018. At the time
guaranteed employment for at least your                of the survey 56.83% of respondents had
first year after qualifying?                           already been approached by overseas nursing
                                                       companies for recruitment.

              Question 6
  90                                                   Question 8: Have you considered moving
  80                                                   to the private sector within Ireland after
  70                                                   qualifying? (If you have not been on
  60                                                   clinical placement in a private hospital)
  50                                             Yes
  40                                             No    80                Question 8
  20                                                   60
  10                       17.57                                          59.95%
 Answer Choices                      Responses
 Yes                                 82.43%            20
 No                                  17.57%
Of the respondents that are considering                 0                        Yes   No
traveling (as per question 3) 82.43% would
delay their departure if their employer
guarantees employment for at least the first            Answer Choices                       Responses
                                                        Yes                                  59.95%
year.                                                   No                                   40.05%
Question 7: Have you been approached by                59.95% of the respondents confirmed that
                                                       they would consider moving to the private
overseas nursing companies to recruit you
                                                       sector in the Republic of Ireland.
to their service?
                                                       Question 9: How likely are you to stay in
                  Question 7                           your teaching hospital after qualifying?
                     Yes    No

                                                                     Question 9
                                                                  Very Likely
 50               56.83
                                                                  Maybe if I don’t get any other offers
                             43.17                                Very unlikely
 20                                                                      40.05     39.81

  0                                                     30
 Answer Choices                  Responses
 Yes                             56.83%                 10
 No                              43.17%

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                                 MAY 2018 INMO
Page |9

 Answer Choices                    Responses            Question 11: Would you consider moving
 Very Likely                       40.05%
 Maybe, if I don’t get any other   39.81%
                                                        to a work place closer to home?
 Very Unlikely                     20.14%
59.95% of respondents are either very unlikely                        Question 11
to remain in their teaching hospital after
qualifying or are considering other offers.
                                                                                          Yes; This is due
                                                                                          to cost

Question 10:
Has your current employer offered you a
job on qualifying?                                                                        Yes: you would
                                                                                          prefer to live
                                                                                          closer to/at
                Question 10                               35.9
                                                                                26.51     home

                                           6.47                                           Yes: you are
                                                                                          not enjoying
                                      Yes: Full Time                         31.81        your current
                                      permanent              5.78                         workplace
                     17.99                                                                and/or where
                                      Yes: Part Time
                                                                                          you are living
                                                                                          No, Not yet
       74.58                          Yes: Fixed Term

                                                         Answer Choices                  Responses
                                                         Yes: This is due to cost        26.51%
                                                         Yes: You would prefer to live   31.81%
                                                         closer to/at home
                                                         Yes: You are not enjoying       5.78%
 Answer Choices                Responses
                                                         your current work place
 If yes: Full time Permanent 17.99%                      and/or where you are living
 If yes: Part Time             0.96%                     No not yet                      35.90%
 If yes: Fixed term contract 6.47%
 No                            74.58%
The closing date of the survey was March 7th            64.1% of the respondents would like to move
2018. 74.58% of respondents had not                     to a workplace closer to home. 26.51% say that
received any offers of employment from their            this is due to cost.
employer upon graduation.                               35.9% would not like to move closer to home.

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                             MAY 2018 INMO
P a g e | 10

Question 12: Have you been provided                Question 14: Have you found adequate
with information regarding portfolios or           staffing levels in your workplace to support a
interviews by your employer?                       positive learning environment?

                                                                 Question 14
                Question 12





                      Yes      No

    Answer Choices                   Responses
    Yes                              12.26%
    No                               87.74%
87.74% of respondents have not been
                                                                     Yes       No
provided with information regarding portfolios
                                                    Answer Choices               Responses
or interviews by the employer.
                                                    Yes                          23.98%
Question 13: Would you be interested in an          No                           76.02%
INMO led seminar in C.V., interview and
portfolio preparation?
                                                   When asked if interns have found adequate
    Answer Choices                  Responses      staffing levels in the workplace to support a
    Yes                             89.69%         positive learning environment 76.02% replied
    No                              10.31%         no.


    2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                  MAY 2018 INMO
P a g e | 11

Summary of Findings                                 Section 4

From the survey results in Question 3 it is clear   Recommendations
that nursing and midwifery interns are
considering emigration upon qualifying in
2018. (70.98%)                                      The respondents comments in Section 5
                                                    highlight the reality of the issue of nurses pay
59.95% of respondents are considering moving
                                                    in relation to other Allied Health-Care
to the private sector where working conditions
                                                    Professionals (AHP) and in relation to Health
and incentives are more favourable.
                                                    Care Assistants (HCA’s).
Incentives are urgently required to persuade
                                                    Nurses and midwives should be paid on par
graduating nurses and midwives to remain
                                                    with other Allied Health Care Professionals
working within the public health service. (See
                                                    with comparable grades of education and
Question 5)
Increases in pay ranked the most favourable
                                                     Profession with QQI Level Starting Salary
incentive that would entice graduates to
                                                     8 qualification
remain in the public health services. (See
                                                     Occupational Therapist         €35,319
Question 4)
                                                     Physiotherapist                €35,319
Improved staffing levels and working                 Speech and Language €35,319
conditions ranked the second highest incentive       Therapist
amongst respondents (Question 4.) From the           Staff Nurse/Midwife            €28,768
respondent’s comments in Section 4 it is clear      The nurse/midwife is responsible for patient
that interns are considering alternative places     care and has a statutory obligation to maintain
of work to escape the conditions they               the safety and welfare of patients. They may
experienced in their training hospitals.            delegate aspects of care to a Health Care
                                                    Assistant (HCA) whose education level is QQI
At the time of the Survey (21st February-7th        Level 5. However, a staff nurse/midwife must
March 2018) 56.83% of respondents had been          reach point 5 of the salary scale before she/he
approached by overseas nursing companies to         exceeds the maximum point of the Health Care
recruit them as seen in Question 7. Only            Assistant salary scale. Nurses and midwives
17.99% of respondents had been offered              believe it is unjust that they have a higher level
contracts by the HSE as per Question 10.            of education, with greater responsibility, and
In Question 14 we see that 76.02% of                statutory responsibility and accountability yet
respondents found staffing levels in the            they are paid less than their HCA colleagues.
workplace where they are training did not           Addressing these issues with pay will have a
support a positive learning environment. This       cascading effect whereby this significant
is further supported by the comments in             incentive will influence increases in staffing
Section 5.5.                                        levels, increase staff morale and consequently
                                                    improve some aspects of the working
                                                    It is extremely difficult for nurses and midwives
                                                    to pay current rates of rent or to consider
                                                    purchasing a home. House prices rose by 14%
                                                    in 2017 with a further 11% increase expected
                                                    in 2018 (Irish Examiner). In 2017 average rent
                                                    rose nationally by 10.4% to €1227 per month
                                                    (Daft.ie). This equates to approximately

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                        MAY 2018 INMO
P a g e | 12

€14,724 p.a. which is practically all of a newly   The emotional toll of caring has the potential
qualified nurse or midwife’s salary.               to cause physical and psychological harm to
                                                   nurses (Figley, 1999) and therefore on entry to
                                                   nursing and midwifery degree programmes
Recruitment and Retention                          students must be supported and educated on
                                                   the occupational risks.
The supply of nurses and midwives into the
Irish health service predominantly comes from      The HSE and Higher Education Institutions
undergraduate education programmes and             (HEI) must address this issue with a proactive,
international recruitment. To address the          solution focused, and supportive strategy for
shortages in nursing and midwifery staffing the    students. According to Dwyer and Hunter
HSE must be more proactive in recruiting new       Revell (2015) ‘nurse educators are responsible
graduates in Ireland.                              for preparing students to meet the challenges
                                                   of today’s complex practice environment’.
Question 12 and 13 also highlight concerns in
relation to portfolios and interviews. Currently   Undergraduate nursing and midwifery degree
interns must go through an interview process       programmes must incorporate self-care,
to access employment in their teaching             resilience training, and enhanced mental
hospitals. Contracts are offered ‘subject to the   health supports into the curriculums as a
usual satisfactory recruitment processes’, as      measure to enhance students coping skills and
outlined in HSE HR Circular 10/2017. The usual     prepare them for working in this challenging
satisfactory recruitment process is not            and complex environment.
sufficient given the current circumstances. The
                                                   Supportive learning Environment
interviews are arranged prior to the intern
qualifying as a nurse or midwife, therefor they     Question 14 demonstrates that 76.02% of
cannot be expected to achieve the necessary         respondents found that the staffing levels
standard for recruitment. The teaching              and skill mix were not supportive of a
hospitals do not provide meaningful support or      learning environment. This is strongly
education to prepare the interns for the            reflected in the comments section.
interview process.                                  (Section 5.5)
                                                   The Nurses and Midwives Board of Ireland
                                                   (NMBI) are responsible for the regulation of
Working Conditions                                 the standards of education and training of
                                                   nurses and midwives in Ireland. There are
The respondents highlighted concerns
                                                   concerns going forward in relation to the
regarding working conditions in the comments
                                                   ability of Irish hospitals to support the
section. The main concerns related to long
                                                   education and training of nursing and
hours, demanding workloads, not getting
                                                   midwifery students to the required standards
breaks, not getting to finish on time, lack of
                                                   set out by NMBI. This will have a knock-on
respect for the nursing profession and high
                                                   effect creating further difficulties in recruiting
levels of stress.
                                                   and retaining nurses and midwives in Ireland
 From the comments in Section 5, there is          and needs to be addressed.
evidence to show that stress is a recurring and
                                                   This issue has been raised by the INMO Student
widespread experience for student nurses and
                                                   Section as a matter of concern. Since the
midwives. Many aspects of the professions of
                                                   results of this survey were collected, the INMO
nursing and midwifery may be stressful and
                                                   has checked the ratio of Clinical Placement
according to Suresh et al. (2012) this requires
                                                   Coordinators (CPC) to Students within 9 areas
urgent attention in view of widespread
                                                   that support the training and education of
retention difficulties.
                                                   student nurses and midwives. According to

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                       MAY 2018 INMO
P a g e | 13

NMBI Standards the minimum ratio for CPC’s
                                                     Summary of Recommendations for recruiting
of 1:30 nurses and 1:15 midwives must be
                                                     new graduates:
maintained. The average CPC to Student ratio
seen across the 9 areas that support student             1. Pay competitive rates for nurses and
nurse/midwife training is 1:38.27. It is a serious          midwives of all grades to retain them
concern that the minimum NMBI standards                     within the public services.
designed to protect the public are not being             2. Recruit all graduates that have
achieved. The only area that achieved better                passed the final exams and
than the minimum ratio was in the private                   assignments and have appropriate
sector, with a ratio of 1:26.2. The area with the           levels of competency as outlined by
poorest ratio is at 1:53. Concerns also exist               the Nursing and Midwifery Board of
where the CPC to student ratio does not make                Ireland (NMBI) standards.
allowances for the geographical area to be               3. Offer permanent contracts as an
covered as specified by NMBI.                               incentive to remain within the public
                                                            health services with opportunities
National figures suggest there are currently
                                                            for a career break after 1 year.
127.39 CPC WTE’s and approximately 6600
                                                         4. Provide a structured professional
student nurses and midwives. This suggests
                                                            development plan for each new
that the ratio of CPCs to Students is 1:51.8
                                                            graduate including opportunities for
which falls desperately short of the minimum
                                                            funded post-graduate education and
NMBI Standard.
                                                            accommodating the individual’s
This is another example of the knock-on                     preferences in specialities/areas.
effect of the retention and recruitment                  5. Ensure adequate support and
difficulties across nursing and midwifery                   supervision from appropriately
grades on student learning.                                 qualified and experienced mentors
Since 2015 HEIs have increased the number of                in the workplace.
undergraduate nursing and midwifery places
from 1570 to 1830 in 2017 (an increase of 260).
These additional students require increases in
supports within the HEIs and in the facilities
that support the learning of student nurses and

At all times there must be sufficient registered
practitioners to facilitate the supervision and
support of student nurses and midwives to
achieve the expected learning outcomes of the
programmes. An immediate national review of
compliance with NMBI standards is urgently
required with a focus on availability of Clinical
Placement Coordinators, Student Allocation
Liaison Officers and Preceptors. This issue must
be resolved through recruitment and training
of appropriate nursing and midwifery

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                              MAY 2018 INMO
P a g e | 14

Section 5                                          ‘The staffing levels and the rate of pay are the
                                                   biggest obstacles to wanting to work in a HSE
Respondents Comments                               hospital…. I would love to stay and work, but
In this survey Question 15 gave                    the incentives aren't there and the
                                                   responsibility of looking after 14 patients by
respondents the opportunity to leave an
                                                   myself as a 4th student is too great. What will
open comment. This option was taken up
                                                   it be like when I'm a nurse?’ (2/26/2018 5:38
by 101 respondents out of a total of 417.          PM)
Due to the large number of responses, the
comments were selected and categorised
into the following headings based on the           ‘Throughout my training I worked for an
                                                   agency getting €18 per hour as a care
trends that emerged:                               assistant. I am now nearing registration as an
                                                   RNID, after 4 hard years, travelling a long
5.1 Need for Increases in Pay
                                                   distance. My greatest unease is that my pay as
5.2 Staffing Levels and Working                    an RNID will not reflect the hard work I put in
Conditions                                         over the last 4 years. It is unfair that as the
                                                   RNID you are in charge of the unit but get paid
5.3 Further education and career                   a great deal less than the care assistants.
prospects                                          There's no incentive to remain in Ireland, I
                                                   would be better of going back to the agency
5.4 Emigration                                     working as a care assistant. In essence, 4
5.5 Supported Learning Environment                 years of hard work and extreme stress should
                                                   be reflected in my pay scale.’ (2/22/2018 6:32

5.1 Need for Increases in Pay                      ‘Better pay, better staffing levels, ward clerks
                                                   and cleaners earn more than those with
‘It’s very dis-heartening to get paid more for     bachelors’ (2/22/2018 6:29 PM)
the job I was doing (which was a healthcare
                                                   ‘From a salary point of view all I can say is that
assistant) than a job I spent four years in
                                                   it is a pity as I have worked as a Health Care
college to do!’ (3/7/2018 5:38 PM)
                                                   Assistant for three years and by the time I
‘Why are the HSE care assistants getting paid      qualify as a Registered Nurse it will be more
more than the newly qualified nurses? Who          convenient for me to work as a carer as I will be
have a lot more responsibility on their            paid more money due to my experience and
shoulders?’ (3/7/2018 4:07 PM                      have less responsibilities and less stress but yet
                                                   I love nursing too much And hope for this
‘…I have given 4.5 years to complete my BNSc
                                                   passion to last for a little longer and not burn
degree, only to be paid less, with more
                                                   me out.’ (2/22/2018 6:13 PM
responsibility and worse hours than I had as a
healthcare assistant. Ireland does not value       ‘… if I was offered a post in a private
nurses, I can't imagine why anyone                 organisation I would take this over the HSE
unattached would stay.’ (3/5/2018 11:46 PM)        position due to pay.’ (2/21/2018 5:18 PM)
‘After 12 yrs as a catering assistant for HSE. I   ‘ A lot of the above questions do not apply to
found it a disgrace that after a 4yr degree I      me as I have a young family and won’t be
will be worse off financially. !!’                 traveling. I totally see why young graduates
                 (2/27/2018 1:28 PM)               want to leave. Short staffing, stressful
                                                   environment, no staff engagement or forums
                                                   in decision making, poor facilities, poor
 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                       MAY 2018 INMO
P a g e | 15

management interpersonal skills and poor             was told to be by a manager. We are treated
reward having to work unpaid hours. Mary             so terribly.’ (3/6/2018 4:53 PM)
Harney once said of government pay rises that
                                                     ‘Staffing levels is the main issue, I can't
if you pay peanuts you get monkeys. That’s
                                                     imagine myself staying in Ireland under the
how well nurses are respected and until
                                                     current working conditions’.
nurses call the government/HSE bluff and go
on strike we will continued to be walked over        (2/26/2018 5:01 PM)
and taken for granted.’ (2/21/2018 3:59 PM)
                                                     ‘DEAL WITH INADEQUATE STAFFING LEVELS;
‘Student nurses are overloaded with work and         DANGEROUS ENVIRONMENT TO BE IN FOR
not supported due to very poor staffing levels.      BOTH PATIENTS AND NURSES!!!!! When is the
It’s a disgrace. after spending 4 years in           HR department going to support staff at the
college to become a nurse and get treated like       frontline????’ (2/25/2018 6:30 PM)
a piece of rubbish and payed so bad for the
work we do. This state is a disgrace. There
have been weeks I had no money or no diesel          ‘It is very unfair as a student nurse. You are not
to get to placement’. (Survey respondent on          supported enough by staff nurses as the do not
2/21/2018 2:40 PM)                                   have the time. It is very disheartening to see the
                                                     bad        management        in     hospital    eg.
                                                     Overcrowding, understaffing It is not a
      5.2 Staffing Levels and Working                pleasure to go to work some days it feels like a
                 Conditions                          constant battle of running around after your
                                                     tail. It is not acceptable or fair on nurses or the
‘The staffing levels are shocking in most Dublin     patient. It has to change nobody can stick it if
hospitals and I, along with many of the              it continues. Why are nurses not treated like
students I am training with feel that we are         they would be in a company? I feel
unable to enjoy our internship due to the            undervalued…This is so disheartening as if it
immense amount of pressure put on us to              was their family member on a trolley in the
perform as staff nurses/ in place of staff nurses.   middle of a corridor they would want them to
It is evident that the 2:1 student: staff nurse      receive the best care possible. I feel the fact
ratio is non-existent. I will strongly consider      that the patient is a person is forgotten about!’
leaving the profession once I qualify. This is a
real shame.’(3/7/2018 5.40pm)                        (2/22/2018 5:09 PM)

‘I find it highly unfair that due to the lack of
staffing in most hospitals that its 4th year
                                                     ‘The high work load with insufficient staffing
students are expected to take on all the work
                                                     levels to safely and thoroughly carry out
and responsibility of a fully qualified staff
                                                     duties is what puts me off most as well as not
nurse without any of the same rewards. We
                                                     enough rest time between 13hour days. No
are constantly being put down by doctors as we
                                                     increase in pay or promise of job security can
are 'only students' yet also expected to do
                                                     make up for that for me. We need rolling
things like take bloods and insert cannulas even
                                                     rosters with predictable patterns to allow for
though there is no way that we would even
                                                     knowing our days off in advance and
consider that at this level. We also don't even
                                                     regulations that protect us from doing our 39hr
have proper changing rooms or lockers and due
                                                     weeks back to back with no break in between.
to that, are constantly having our property
                                                     Quality of life and high pressure are the
stolen. I myself have been physically and
                                                     biggest problems in this work environment.’
verbally attacked by numerous patients only
                                                     (2/22/2018 5:50 PM)
to be told that if I take the complaint further
then I won't be offered any work, and that

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                          MAY 2018 INMO
P a g e | 16

‘As an intern practicing feels dangerous as          midwifery altogether. The Maternity services
staffing levels are so inadequate you are            have taken so much from me and given nothing
forced to do things you are not competent to         back. I have turned into a miserable person. I
do. There’s little opportunity to progress in        do not have any hopes for a positive midwifery
your career if you stay here and progression is      career in Ireland. I don’t believe the change is
not encouraged or supported. Nursing in              possible for the women or for us as midwives I
Ireland on under staffed wards is horrific,          don’t expect change will come about within
scary, dangerous and so harmful to patients.         this decade which is a crying shame.’ (Survey
Every day you feel like 90% of your patients         respondent on 2/22/2018 6:36 PM)
did not receive adequate care. Its draining
and is honestly pushing me away from the
nursing career. The conditions for interns is so                    5.3 Emigrating
bad its breeding a generation of nurses that are
ambivalent to delivering high quality patient        ‘As a 22-year-old 4th year student nurse, I will
care.’ (2/21/2018 2:33 PM)                           definitely be emigrating in the following year
                                                     as the working conditions, staffing and pay is
                                                     horrendous in the HSE. If new graduates are
‘No other jobs expect hours of free work a           offered better conditions, pay and contracts I
week plus very often no breaks. In any other         would consider staying at home’. (3/6/2018
job this would not be accepted. Or any other         7:46 PM)
country.’ (2/21/2018 2:12 PM)                        ‘I would like a job in Galway, as that is where
‘For me, working in the maternity services in        my family and friends are. I would consider
the HSE has made me miserable. I am not              moving away if a place in Galway wasn't
working to my autonomy or as the midwife I           available’. (3/5/2018 3:56 PM)
believe I could be somewhere in Australia or in      ‘Will not be staying in Ireland to work unless
the UK or Scotland where I went on an elective.      pay increases and working conditions improve
Until there are further choices for women in         drastically.’ (2/27/2018 9:58 PM)
this country and for me to work I will not be
working in any hospital in Ireland. I would be       ‘The ward I work on is the worst staff ward I
interested in doing community midwifery or           have been on so far in my training, all the
working in a birth centre. I also do not think 12    nurses under the age of 30 have recently
hour shifts suit my lifestyle, having no time with   moved abroad due to work incentives. None
my partner not having weekends or holidays           of this would encourage me to work there
off is not for me. I want to work to live not live   after I graduate’. (2/26/2018 5:18 PM)
to work and missing out on important                 ‘We are aggressively recruited from abroad
relationships with family and loved ones is also     with choice of work areas, subsidized
a factor which deters me extremely. I have also      accommodation. And a clear plan for our
considered work in private fertility clinics for     career development and how they will
this reason. There is an extremely negative          support us in getting there. None of this was
atmosphere in my parent hospital probably            offered by Irish hospitals. I had previously
due to understaffing or burnout. This is not         thought I would stay and work in my training
the kind of environment I wish to work in. If        hospital in an area I love. However, it is
there was more choice for my career as a             disheartening when our training hospitals can’t
midwife, better hours, and a positive work           offer us any of the above. Nurses are fighting
environment I would consider staying. There is       to get to CPR courses let alone thinking of
a long way to go for maternity services in           further development. Majority of students on
Ireland. If I could not do what I wanted here        my course is staying for one year in their
without moving away I would even give up             training hospital but already have jobs lined

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                        MAY 2018 INMO
P a g e | 17

up for leaving next year. Irish hospitals trained    treated like a slave after 4 hard years of
us but unfortunately past that further               training is demoralizing and deeply upsetting.
educational needs and career progression is          Why would anyone want to stay here when
severely limited. I regret that my decision is to    we can be rewarded (with proper pay and
move away but it’s the best choice for my            adequate patient loads) whilst doing the job
career’. (2/26/2018 9:10 AM)                         we love elsewhere’. (2/21/2018 3:53 PM)

‘This country is a joke! There are 10 in my          5.4 Further       Education      and     Career
group of friends both general and mental             Prospects
health nurses and we all plan on immigrating
due to the pay levels and understaffing within       ‘As a young person, one is supposed to be
the hospitals! Something needs to be done..          exciting and motivated as they enter their
Fast!’ (2/22/2018 10:13 PM)                          career of choice but since January I have lost
                                                     what little faith I had left. I have cried almost
‘As a 4th year intern student, I find the staff      every week and have counted far more bad
levels disgraceful. I find the level of pay we       days than good… I’m not a martyr and
receive difficult, we work 39 hours a week and       although I am made feel guilty for stating this,
would need a second job just to support our          I value my capabilities and intelligence and
expenses and daily living. Also, the working         want to work somewhere I feel I can apply my
conditions make our job so harder, you come          knowledge and reap the rewards of hard
home from work stressed and dread going in           work. There are many newly qualified nurses
the next day, nobody wants to be in a                working on the ward I’m currently placed and
profession like that. Talking to my colleagues,      they’re both physically and mentally burnt out
we plan on travelling as we don’t want to            at this early stage in their career. This is not
endure the working conditions here in Ireland.       just regarding the inconceivable staffing
The conditions the patients have to endure, is a     levels but the archaic healthcare system that
disgrace and it results in poor patient care due     sees nurses as second class human beings.
to the working environment. What has to be           Their work is not appreciated, and their
done for a change to happen?’ (2/22/2018 8:38        intelligence and professional opinion
PM)                                                  disregarded…. I know I could be an excellent
‘I feel that the staff are great and do their best   staff nurse and know I am valuable to the
but as the staffing levels are so low, the work      ward I work on. As of right now, I’m more
environment can be difficult and this makes          competent that some of the staff who have
working abroad more appealing at the                 had their spirit and humanity tarnished by
moment’ (2/22/2018 6:08 PM)                          their careers. With a heavy heart I have no
                                                     intentions of pursuing a career in nursing.
‘I would love to stay and nurse in Ireland,          Until January I planned to emigrate but
however the staffing levels and poor pay are         knowing I would want to return home
just not endearing me to stay here for the rest      eventually I’ve decided to invest in myself and
of my life. I intend to leave the country and at     undertake a business masters. The reality is I
the moment I am not anticipating returning           believe I could have more of an impact on this
home any time soon. Opportunities for                broken system if I’m not a nurse. I will miss a
experience and great pay are waiting for me          lot about nursing but I feel naive to believe I
and my colleagues abroad. Unfortunately,             will have a successful and fulfilling career in
there is no appeal to staying in Ireland where       nursing in this country.’ (2/23/2018 8:39 AM)
we are under appreciated and over worked. I
went into nursing because I love helping those
in need, not for the money. However, being

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                         MAY 2018 INMO
P a g e | 18

5.5 Supported Learning Environment                    As a 4th year student nurse, there is a lot of
                                                      responsibility on us as the wards are extremely
‘Students rarely get a given a preceptor to           understaffed and more jobs are expected of
work with, which makes it nearly impossible           nurses. Usually, I love being a nurse and have
to get meetings done. Also, as staff levels are       great satisfaction from the job. The nurses on
low, students are treated more likes HCA’s            the ward are mostly helpful and supportive.
and this makes it difficult to learn any nursing      However, the working conditions and the
skills’. (3/5/2018 3:59 PM)                           staffing levels in hospitals has made it harder
                                                      for me to like nursing. I often come home
                                                      extremely stressed and exhausted from work.
‘Improvements needed desperately within               There is not enough support for us……..So far,
disability services for students. We need extra       my internship has been very stressful as the
strong CPC support and backup from the HSE            wards are so busy and also with my fee being
within such services to stop these services using     due in the middle of it. I also think it's
students as everyday staff to cover their sick        extremely unfair on us that we have 100%
staff days. We need structure in learning             attendance, so we have to repeat every day
regardless of staffing issues.’ (2/27/2018 1:14       we miss compare to other university courses
PM)                                                   when they are on co-op and do not have to
                                                      repeat their missed days. However, I find that
                                                      nursing is the right job for me and if I had it
‘The stress of juggling clinical placement            back I still would choose nursing. Hoping these
hours    and     academic     workload  is            suggestions will be acted upon as I feel very
overwhelming and negatively impacts the               strongly about them. (2/22/2018 7:59 PM)
students’. (2/27/2018 12:23 AM)
                                                      Due to low levels of staff I felt that my
                                                      learning was severely affected and at times
                                                      felt unsafe/under supported on clinical
‘The current rate of pay for fourth year interns
                                                      placement. (2/22/2018 5:52 PM)
makes it very difficult to live on as it is so poor
and the current state of the HSE makes it very        Hospitals are unfortunately understaffed
difficult to both work and learn in’.                 therefore due to no fault of their own nurses
                                                      are unable to provide adequate training for
(2/23/2018 2:52 PM)
                                                      student nurses. Sad to say.
                                                      (2/22/2018 3:33 PM)
‘Too little staff makes learning outcomes poor
and patient safety at risk which is a major
concerns for us on being safe in our practise
and guarding our pins once we qualify’
(2/22/2018 10:11 PM)

‘More staff is needed. As a student nurse the
conditions can be dangerous to work in when
there is not adequate amounts of staff.
Students can be expected to care for up to 8
patients on their own when staffing is short.
This is overwhelming for students and the
patient centred care is reduced for each
individual in hospital.’ (2/22/2018 7.13PM)

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                        MAY 2018 INMO
P a g e | 19

Authors:                        Neal Donohue, Student/New Graduate Officer INMO
                                Phil Ní Sheaghdha, General Secretary INMO
Reviewed by:                    Niamh Adams, INMO Librarian
                                Tony Fitzpatrick, Head of Industrial Relations, INMO


We thank the INMO President and the Executive Council of 2017/2018 for their ongoing
support of this project.

We would also like to acknowledge the work of the INMO Library Staff and the INMO
Information Department for their help and guidance.

We must also express profound gratitude to the 4th Year internship students of 2018 who
participated in this study, to the INMO Student Section and Youth Forums, INMO Clinical
Placement Coordinator Section, and the Student Allocations Liaison offers Section.

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                    MAY 2018 INMO
P a g e | 20

Reference List:

Department of Health Consolidated Salary Scales in Accordance with FEMPI 2015 and the Public
Service Services Stability Agreements 2013-2020

Casey, J. (2016) 600 staff attacked per year in HSE hospitals, Irish Examiner, 5 December. Available at:
(Accessed on 26th April 2018)

Dwyer, P.A. Hunter Revell, M. (2015) preparing students for the emotional challenges of nursing, an
integrative review. Journal of Nursing Education, Vol. 54, No. 1. pp. 7-12

Figley, C.R. (1999) Compassion Fatigue: Towards a new understanding of the cost of caring. In B.H
Stramm (Ed.), Secondary traumatic stress: Self-Care issues for clinicians, researchers, and educators
(pp.3-28). Lutherville, MD: Sirdan

Department of Health (2018) Framework for safe nurse Staffing and Skill Mix in General and Specialist
Medical and Surgical Care Settings in Adult Hospitals in Ireland

Health Service Executive (2007-2016) Health Service Employment Reports.

Health Service Executive (2017) HR Circular 010/2017 – Nurse/Midwifery Recruitment and Retention

Lyons, R. The Daft.ie Rental Price Report. An analysis of recent trends in the Irish rental market 2017



Nursing and Midwifery Board of Ireland, Standard 7: practice placements, learning environment and
competence assessment.


 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                           MAY 2018 INMO
P a g e | 21

Department of Health (2016) Implementation of the Recommendations of the Report of the Review
of Undergraduate nursing and Midwifery Degree programmes (2012)

Irish Nurses and Midwives Organisation (201)7 Nursing and midwifery Internship Survey

Irish nurses and Midwives Organisation (2017) Submission to Public Service Pay Commission phase II,
November 29th2017

Scott, A, Kirwan, M, Matthews, A, Lehwaldt, D, Morris, R, Staves, A (2013) Report of the Irish RN4CAST
2009-2011 A nursing workforce under strain.

Suresh, P., Matthews, A., Coyne, I. (201) stress and Stressors in the Clinical Environment, Journal of
Clinical Nursing, 22, 770-779

 2018 NURSING AND MIDWIFERY INTERNSHIP SURVEY                                         MAY 2018 INMO
You can also read
NEXT SLIDES ... Cancel